Journal of Medicine and Philosophy , 34 : 487 495, 2009

doi:10.1093/jmp/jhp037
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Sex, Immorality, and Mental Disorders
BERNARD GERT
Dartmouth College and Dartmouth Medical School, Hanover, New Hampshire, USA
CHARLES M. CULVER
Barry University, Miami Shores, Florida, USA
Although the denition of a mental disorder has remained essen-
tially the same from Diagnostic and Statistical Manual of Mental
Disorder, Third Edition, Revised ( DSM-III-R ) through DSM-IV to
DSM-IV-TR , the account of the paraphilias has changed continu-
ally. Although the denition in all the DSM s explicitly rules out de-
viant sexual behavior as sufcient for labeling someone as having
a mental disorder, deviant sexual behavior counts as sufcient for
all the paraphilias in DSM-III-R . In DSM-IV , the account of all the
paraphilias is made consistent with the denition. In DSM-IV-TR ,
mere deviant sexual behavior is not sufcient for being classied as
having a paraphilia, but immoral deviant sexual behavior is. Thus,
in DSM-IV-TR , only those paraphilias that involve immoral deviant
sexual behavior are inconsistent with the denition, but deviant
sexual behavior by itself does not count as a mental disorder.
Keywords: deviance , DSM , harm , immorality , mental disorder ,
paraphilia , sex
I. INTRODUCTION
It is fairly common for people to regard deviant sexual behavior as immoral or
as the symptom of a mental disorder; often it is regarded as both immoral and
as a symptom of a mental disorder. That there is something wrong with deviant
sexual behavior is not only commonly held by people without professional
expertise in the areas of mental disorders but also by many psychiatrists. Not
only are all mental disorders abnormal in the sense that they occur in a relatively
small minority of the population but also abnormality is an essential feature of a
Add ress correspondence to: Prof. Bernard Gert, Department of Philosophy, Dartmouth
College, Hanover, NH 03755, USA. E-mail: bernard.gert@dartmouth.edu
Bernard Gert and Charles M. Culver 488
mental disorder. However, although the denition of mental disorder must
include abnormality as a necessary feature, abnormality, even abnormality in
feelings or behavior, is not a sufcient condition for having a mental disorder.
This has been acknowledged by the denition of mental disorder in every Diag-
nostic and Statistical Manual of Mental Disorders ( DSM ) for over twenty years.
Labeling some behavior as a symptom of a mental disorder is a serious
matter. People can be, and sometimes are, dismissed from a sensitive job or
position because they have a condition that is labeled as a mental disorder.
Deviant sexual behavior is very likely to be mistakenly labeled as a symptom
of a mental disorder, so it is especially important to be careful when consid-
ering whether to classify feeling like behaving, or behaving in a sexually
deviant manner as a symptom of a mental disorder. Even though some
persons engage in deviant sexual behaviors that many regard as repugnant
or even as immoral, according to the denitions in every DSM for the last
twenty years, that is not sufcient for that behavior to be classied as a
symptom of a mental disorder. A heterosexual man may enjoy sexual excite-
ment by dressing in womens underclothing and although such behavior is
sexually deviant, if it is ego-syntonic, that is, he is not bothered by feeling
like behaving in this way or actually behaving in this way, he does not have
a mental disorder according to these denitions.
The denition of mental disorder makes it clear that deviant sexual behav-
ior that does not cause any problems for the person exhibiting that behavior,
that is, does not cause him clinically signicant distress or impairment in
social, occupational, or other important areas of functioning, is not a mental
disorder. Nonetheless, in an earlier DSM that included such a denition of
mental disorder, Transvestic Fetishism, that is, the kind of behavior of a het-
erosexual man described in the previous paragraph, was labeled as a kind
of mental disorder that used to be called a sexual disorder but is now called
a paraphilia. This shows how powerful the inclination is to regard deviant
sexual behavior as a symptom of a mental disorder.
Although later editions of DSM did not classify ego-syntonic Transvestic
Fetishism as a mental disorder, many in the psychiatric community contin-
ued to view many sexually deviant behaviors as symptoms of mental disor-
ders. However, because some sexually deviant behaviors do not cause any
harms or problems for anyone, psychiatrists concentrated on those sexually
deviant behaviors that involve an unconsenting other person. Even though
the person exhibiting the sexually deviant behavior is not suffering in any
way, the fact that someone is suffering, or at increased risk of suffering, in-
clined some psychiatrists to want to classify immoral sexually deviant behav-
iors as symptoms of mental disorders. In the most recent DSM (American
Psychiatric Association , 2000), this resulted in labeling those sexually deviant
behaviors that were immoral as symptoms of mental disorders.
Given the tremendous improvement in psychiatric diagnoses and treat-
ment, including some discoveries about the genetic predispositions for some
Sex, Immorality, and Mental Disorders 489
mental disorders, it is discouraging to see psychiatry revert to its former role
as guardian of sexual morality. If psychiatry is to take its place as a branch
of medicine, mental disorders, like physical disorders, should be limited to
conditions that cause harm to the person with the disorder. In this paper, we
shall investigate in detail the problems that are caused by the strong inclina-
tion of psychiatrists to regard immoral sexually deviant behaviors as symp-
toms of mental disorders, even when the person with the disorder is suffering
no harm.
II . THE CONTEXT OF THE PROBLEM
A central conceptual task in both psychiatry and clinical psychology is to
provide a denition of the term mental disorder that will be helpful in
determining whether a condition should be labeled as a mental disorder.
Such a denition not only must include all the clear cases of mental dis-
orders and exclude all conditions that are clearly not mental disorders but
also must resolve all controversial cases in a defensible way. It must also
make clear that, apart from the symptoms of a disorder, mental disorders
do not differ from physical disorders in any signicant way. The past sev-
eral volumes of the DSM have provided such a denition of mental disor-
der. However, the authors of the DSM texts (with the exception of DSM-IV )
seem not to have followed their texts own denition in their discussion
of the paraphilias, one important kind of mental disorder. According to
the most recent DSM (American Psychiatric Association, 2000) criteria
for being a paraphilia, some conditions are labeled as mental disorders
although they do not satisfy the DSM-IV-TR denition of mental disorder.
In particular, with regard to the kind of behavior included in the paraphilias,
DSM-IV-TR seems to count immoral behavior as sufcient to label a condition
as a mental disorder.
Plato claimed that all immoral behavior was the result of some disorder in
the soul, but almost no one now accepts this view. Although some immoral
behavior may be the result of a disorder in the soul, or what we would now
call a mental disorder, some immoral behavior is due to other causes, such
as the lack of the kind of impartiality that morality requires. People some-
times act immorally, that is, unjustiably break a moral rule that prohibits, for
example, hurting another and deceiving, in order to benet themselves or
their family or friends; and they do not have any mental disorder at all. It is
generally recognized that immoral behavior is the kind of behavior that
causes, or increases the probability of, someone other than the agent to suf-
fer some harm, that is, death, pain, disability, or loss of freedom. Whereas a
malady, whether a physical disorder, for example, meningitis, or a mental
disorder, for example, schizophrenia, is a condition that causes or increases
the probability that the agent himself will suffer these harms. It may be that
some immoral behavior also causes, or increases the probability, that the
Bernard Gert and Charles M. Culver 490
agent will suffer some harm, but what is responsible for classifying that kind
of behavior as immoral is that it causes, or increases the probability of,
someone other than the agent to suffer some harm. Similarly, it may be that
having a malady causes, or increases the probability of, someone other than
the agent to suffer some harm, for example, because the disorder is highly
contagious, but what is responsible for classifying a condition as a malady is
that it causes or increases the probability that the agent will suffer some
harm.
III . DSM-IV-TR DEFINITION OF MENTAL DISORDER
DSM-IV-TR explicitly states: A compelling literature documents that there is
much physical in mental disorders and much mental in physical disor-
ders. It is recognized that mental disorders differ from physical disorders
primarily in the kinds of symptoms that are suffered, for example, behavior
and feelings, but that the essential features of a mental disorder and a physi-
cal disorder are the same. No one claims that any condition counts as a
physical disorder unless it causes, or increases the probability of, the agent
suffering some harm. If a person has a condition such that it causes, or in-
creases the probability of, someone other than the agent suffering some
harm, but does not cause, or increase the probability of, the agent suffering
some harm, then that person may be regarded as a carrier but not as having
a physical disorder, for example, typhoid Mary. The denitions of mental
disorder from DSM-III-R to DSM-IV to DSM-IV-TR make clear that to have a
mental disorder is to have a condition that causes, or increases the probabil-
ity of, the agent suffering some harm.
1

In DSM-IV , each of the mental disorders is conceptualized as a clinically signicant
behavioral or psychological syndrome or pattern that occurs in an individual and
that is associated with present distress (e.g., a painful symptom) or disability (i.e.,
impairment in one or more important areas of functioning) or with a signicantly
increased risk of suffering death, pain, disability, or an important loss of freedom.
2

In addition, this syndrome or pattern must not be merely an expectable and cul-
turally sanctioned response to a particular event, for example, the loss of a loved
one. Whatever its original cause, it must currently be considered a manifestation
of a behavioral, psychological, or biological dysfunction in the individual. Neither
deviant behavior (e.g., political, religious, or sexual) nor conicts that are primar-
ily between the individual and society are mental disorders unless the deviance
or conict is a symptom of a dysfunction in the individual, as described above
( DSM-IV-TR , xxxi).
This DSM denition was used to make important revisions in the account
of the paraphilias in DSM-IV . We have defended this denition against some
signicant criticism by Jerome Wakeeld.
3
Of course, we recognize that there
is much more agreement on what counts as the paradigm cases of mental
disorders (schizophrenia, bipolar disorder, phobias, and compulsions), than
Sex, Immorality, and Mental Disorders 491
on the general denition, but a general denition is useful in deciding about
the controversial cases. The DSM-IV denition of a mental disorder not only
includes all the clear cases of mental disorders and excludes all the clear
cases of conditions that are not mental disorders but also is useful in decid-
ing about the controversial cases. DSM is such an ofcial accepted account
of mental disorders that for psychiatrists to be reimbursed by an insurance
company or the government for treating a patient they usually must classify
the patients mental disorder by listing the number assigned to that disorder
by the most recent edition of the DSM .
IV . ACCOUNT OF THE PARAPHILIAS IN DSM-III-R, DSM-IV , AND
DSM-IV-TR
In DSM-III-R , the account of the paraphilias did not require that a person
with the paraphilia be suffering from a condition that was associated
with present distress (e.g., a painful symptom) or disability (i.e., impairment
in one or more important areas of functioning) or with a signicantly
increased risk of suffering death, pain, disability, or an important loss of
freedom. All that was required was that the person behaves in a way
described by the account of the paraphilia. For example, the dening
criteria of the paraphilia Transvestic Fetishism in American Psychiatric
Association (1987, 288 9) are
A. Over a period of at least six months, in a heterosexual male, recurrent
intense sexual urges and sexually arousing fantasies involving cross-
dressing.
B. The person has acted on these urges or is markedly distressed by them.
Note that, according to criterion B, it is sufcient for a person to be diag-
nosed as having the mental disorder of Transvestic Fetishism simply because
he has acted on these recurrent intense sexual urges and sexually arousing
fantasies involving cross-dressing. That person need not be distressed by
his behavior nor need he be at a signicantly increased risk of suffering
death, pain, disability, or an important loss of freedom. Contrary to the de-
nition of a mental disorder in DSM-III-R , which says, Neither deviant behav-
ior (e.g., political, religious, or sexual) nor conicts that are primarily between
the individual and society are mental disorders, according to DSM-III-Rs
criterion B, exhibiting deviant sexual behavior is sufcient to be labeled as
having the mental disorder of Transvestic Fetishism.
This inconsistency was pointed out in the article, A Sex Caused Inconsis-
tency in DSM-III-R : The Denition of Mental Disorder and the Denition of
Paraphilias ( Gert, 1992 ). This inconsistency was unacceptable to the editors
of DSM-IV . They changed the criteria for the paraphilias so that acting in a way
described by the paraphilia was no longer sufcient to be classied as having
the paraphilia. Although Criterion A remained the same, there was a signicant
Bernard Gert and Charles M. Culver 492
change in criterion B for Transvestic Fetishism in American Psychiatric
Association (1994, 530 1) and American Psychiatric Association (2000, 574 5):
A. Over a period of at least six months, in a heterosexual male, recurrent,
intense sexually arousing fantasies, sexual urges, or behaviors involving
cross-dressing.
B. The fantasies, sexual urges, or behaviors cause clinically signicant
distress or impairment in social, occupational, or other important areas
of functioning.
According to revised criterion B, which in DSM-IV is included as a crite-
rion for all the paraphilias, mere deviant behavior is no longer sufcient for
a person to be classied as having a paraphilia. In DSM-IV , all the paraphilias
require that the person with the paraphilia have a condition such that it
causes, or increases the probability of, the agent to suffer some harm. Thus,
DSM-IV achieved consistency between its denition of a mental disorder and
its account of the paraphilias. Merely acting in the way described by the
paraphilia was no longer sufcient for being diagnosed with that paraphilia.
Mental disorders in DSM-IV were now, except for their primary symptoms,
essentially the same as physical disorders, that is, the person suffering the
disorder, mental or physical, had to have a condition that was causing or
increasing the risk of suffering one or more of the harms: death, pain, dis-
ability, or loss of freedom.
V . MENTAL DISORDERS VERSUS IMMORAL BEHAVIOR
However, in DSM-IV-TR , a different inconsistency arose. For Transvestic Fe-
tishism, the revised Criterion B, The fantasies, sexual urges, or behaviors
cause clinically signicant distress or impairment in social, occupational, or
other important areas of functioning, remained. However, not all paraphil-
ias included the revised Criterion B. For ve paraphilias, namely Exhibition-
ism, Frotteurism, Pedophilia, Sexual Sadism, and Voyeurism, behaving in the
way described by the paraphilia is, as in DSM-III-R , sufcient to allow a
condition to be classied as a paraphilia. The denition of a mental disorder
in DSM-IV-TR remains the same as in DSM-IV , that is, it requires that the
person with a mental disorder be suffering, or be at increased risk of, death,
pain, disability, or an important loss of freedom. DSM-IV-TR does not label
all paraphilias as mental disorders merely because they involve acting in a
way described by the paraphilia. In DSM-IV-TR , the only conditions classi-
ed as paraphilias merely because they involve acting in a way described by
the paraphilia are those associated with causing, or increasing the probabil-
ity of, an unconsenting person other than the agent, suffering some harm.
In DSM-IV-TR , with regard to the paraphilias, behaving in a deviant manner
is not sufcient for having a paraphilia; it is also required that one behave
in a way that causes, or increases the probability of causing, harm for some
Sex, Immorality, and Mental Disorders 493
unconsenting person, that is, doing what would normally be regarded as
acting immorally.
In DSM-IV-TR , with regard to the paraphilias, the distinction between be-
havior that causes, or increases the probability of, some unconsenting per-
son suffering some harm, that is, immoral behavior, and a condition that
causes, or increases the probability of, the agent suffering some harm, that
is, a mental disorder, is eliminated. Consider the eight paraphilias listed in
DSM-IV-TR : Exhibitionism, Fetishism, Frotteurism, Pedophilia, Sexual Masochism,
Sexual Sadism, Transvestic Fetishism, and Voyeurism. For the three paraphil-
ias that are not associated with causing, or increasing the probability of an
unconsenting person suffering some harm: Fetishism, Sexual Masochism,
and Transvestic Fetishism, the account retains the requirement that the per-
son having the paraphilia is suffering, or has an increased risk of suffering,
some harm. However, for the ve paraphilias that are associated with caus-
ing, or increasing the probability of an unconsenting person suffering some
harm: Exhibitionism, Frotteurism, Pedophilia, Sexual Sadism, and Voyeur-
ism, it is sufcient that the person act on the desires characteristic of the
paraphilia.
Sexual Masochism is not a paraphilia simply because the person with it acts
on his masochistic desires, but Sexual Sadism is a paraphilia simply because
the person with it acts on his sadistic desires with an unconsenting person.
This result is the odd conclusion that when considering a sadomasochistic
couple, if both the sadistic partner and the masochistic partner consent to their
relationship, the sadistic partner is not diagnosed as having a mental disorder,
but if the masochistic partner does not consent then the sadistic partner is
diagnosed as having a mental disorder. This makes it clear that with regard to
the paraphilias, DSM-IV-TR does not distinguish between behavior that causes,
or increases the probability of an unconsenting person suffering some harm,
that is, immoral behavior, and a condition that causes, or increases the prob-
ability of, the agent suffering some harm, that is, a mental disorder.
DSM-IV-TR does not explain why it reverts to the DSM-III-R form of crite-
rion B for ve paraphilias: exhibitionism, frotteurism, pedophilia, sadism, and
voyeurism. But since DSM-IV-TR does retain DSM-IVs account of three of the
paraphilias, fetishism, sexual masochism, and Transvestic Fetishism, it clear
that DSM-IV-TR has not simply gone back to regarding deviance as sufcient
for having a paraphilia. What has been added to deviance is immoral behav-
ior. Consider a voyeur who is not distressed by his voyeurism. In 1987, ac-
cording to DSM-III-R , he has a mental disorder if he acts on his urges: in 1994,
according to DSM-IV , he does not have a mental disorder if he does not suffer
clinically signicant distress, even if he acts on his urges; but in 2000, accord-
ing to DSM-IV-TR , he once again has a mental disorder if he acts on his urges.
But in DSM-IV-TR , that is no longer merely due to voyeurism being deviant
sexual behavior but also includes the fact that such behavior increases the
probability that some unconsenting person will suffer some harm.
Bernard Gert and Charles M. Culver 494
VI . CONCLUSION
For those paraphilias that involve deviant sexual behavior that increases the
probability that an unconsenting person will suffer some harm, the psychia-
try professions authoritative diagnostic manual seems to change a condi-
tions mental disorder status every time a revised edition is issued. The reason
for regarding deviant sexual behavior involving an unconsenting person,
namely the behavior involved in voyeurism and the related four paraphilias,
as mental disorders has changed from DSM-III-R to DSM-IV-TR . However,
the account of these paraphilias in DSM-IV-TR is still inconsistent with the
denition of a mental disorder that has been essentially unchanged in all
DSM s from DSM-III-R to DSM-IV-TR . Appendix D in DSM-IV-TR ( Highlights
of Changes in DSM-IV Text Revision ) notes this change in diagnosing some
of the paraphilias (840), but no attempt is made to explain or justify it.
This regression to the DSM-III-R criterion for these ve paraphilias is a
mistake because it confuses behavior that causes, or increases the probabil-
ity of, an unconsenting person suffering some harm, that is, immoral behav-
ior, with having a mental disorder. For a person to have a mental disorder,
the individual suffering harm must be the person with the disorder, not
someone else (the victim in the moral sense). This is abundantly clear from
DSM-IV-TR s denition of mental disorder. Once again it appears that the
editors of DSM have ignored their own denition of mental disorder. They
have impeded the laudatory goal of making psychiatry one of the branches
of medicine. With regard to the paraphilias, they have reverted to making
psychiatry a guardian of sexual morality. We hope that the editors of DSM-V
do what the editors of DSM-IV did and revise the criterion of the paraphilias
so that they are all consistent with the denition of mental disorder that has
remained essentially unchanged since DSM-III-R .
NOTES
1 . The words, and culturally sanctioned, were not included in the DSM-III-R denition but,
except for that addition, the denitions in all three editions of DSM are identical.
2 . We think that loss of pleasure should have been included in this list.
3 . See Chapter 7 in Gert, Culver, and Clouser (2006) , Gert and Culver (2004) , and Wakeeld
(1992a) and (1992b) .
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